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Michigan Gaming Control Board
DISASSOCIATED PERSONS LIST
APPLICATION FORM
The Michigan Gaming Control Board offices are barrier-free and accessible to persons with special needs. Persons needing help with reading, writing, hearing, or other special accommodations or assistance, under the Americans with Disabilities Act, are invited to make their needs known to the Michigan Gaming Control Board at
(313) 456-4100 to make necessary arrangements for such special accommodations or assistance.
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Michigan Gaming Control Board
Disassociated Person’s Application Documents
This application packet contains information regarding placement on the Disassociated Person’s List (DPL). It is strongly recommended you contact the Compulsive Gamblers helpline at 1-800-270-7117 prior to completion of these documents. There are people ready to coordinate an initial consultation with a qualified counselor for your possible gambling addiction. The Michigan Department of Health and Human Services provides this care.
Please read this instruction sheet and all the information enclosed in this application packet (you must initial each page). The following documents are included in this packet:
· Application Required Reading - Section 432.225 (Disassociated Persons) Michigan Gaming Control & Revenue Act, P.A. 69 of 1997, as amended. Please read and initial each page.
· Application for Placement on the list of Disassociated Persons Form - Please complete the first page and answer the questions on pages 2 and 3. It is important that you read and initial each page. Please do not sign the last page until your appointment. It will be notarized at the MGCB office.
· Applicant’s Supporting Affidavit and Release Form - Please read and initial each page. Please do not sign the last page until your appointment. It will be notarized at the MGCB office.
· Addendum – Please read and initial this page.
When you are ready to complete the application process, please contact Ms. Sandra Johnson, DPL Coordinator or Ms. Karen Finch, Administrative Services Section Manager at (313) 456-4100 to schedule your appointment.
Your appointment will be scheduled at the MGCB office of your choice: Cadillac Place (formerly the GM Building), 3062 West Grand Blvd., Suite L-700, Detroit, Michigan 48202 or the Lansing, Michigan office. Please bring this application to your appointment. Also note, your photograph will be taken at your appointment and is required. You must appear in person for processing and bring driver’s license or current government issued photograph identification to the appointment.
Upon completion of the application process, you will receive a copy of your completed application, a Confidential Notice of Placement and a Confidential Order of Placement. An Information Update Notification Form will also be provided to you for use when changes occur in your personal application information.
If you are unable to keep your appointment, please call Ms. Sandra Johnson or Ms. Karen Finch at
(313) 456-4100 to reschedule.
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Michigan Gaming Control Board
List of Disassociated Persons Application
Required Reading
Section 432.225 (Disassociated Persons) of P.A. 69 of 1997, as amended
By writing my initials in the upper right hand corner of this page I acknowledge that I have read and fully understand the "Disassociated Persons" Section (432.225) of P.A. 69 of 1997, as amended.
Sec. 25. (1) The board shall create a list of disassociated persons. The board shall, with the assistance of casino licensees, inform each patron of the list of disassociated persons and explain how the patron may add his or her name to the list.
(2) The board may add an individual’s name to the list of disassociated persons if the individual has notified the board in writing of his or her pledge not to visit a casino in this state by filing an application for placement on the list of disassociated persons with the board.
(3) The board shall create and make available an application for placement on the list of disassociated persons. The application shall include all of the following information about the individual who is applying:
(a) Full name and all aliases.
(b) Physical description including height, weight, hair and eye color, skin color, and any other noticeable physical characteristics.
(c) Occupation.
(d) Current home and work addresses and phone numbers.
(e) Social security number.
(f) Date of birth.
(g) Statement that the individual believes he or she is a problem gambler and is seeking treatment.
(h) A photograph suitable for the board and casino licensees to use to identify the individual.
(i) Other information that the board considers necessary.
(4) An individual’s name shall be placed on the list of disassociated persons after all of the following have occurred:
(a) The individual has submitted an application to be placed on the list of disassociated persons to the Michigan gaming control board.
(b) The application has been verified by a representative of the board.
(c) The individual has signed an affidavit in which he or she affirms that he or she wishes to be placed on the list of disassociated persons and authorizing the board to release the contents of his or her application to all casino licensees in this state.
(d) The individual signs a form releasing the state of Michigan, the board, and the casino licensees from any injury the individual suffers as a consequence of placing his or her name on the list of disassociated persons.
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Page 2 - "Disassociated Persons" Section 432.225 of P.A. 69 of 1997 Continuing,
(e) The individual signs a form stating that he or she understands and authorizes all of the following:
(i) That a criminal complaint for trespassing will be filed against him or her if he or she is found on the premises of a casino in this state and he or she will be immediately removed from the casino premises.
(ii) That if he or she enters a casino and wins any money, the board will confiscate the winnings.
(5) An individual who has his or her name placed on the list of disassociated persons shall remain on the list for the remainder of his or her life.
(6) After an application has been submitted to the board, the chairperson of the board shall file a notice of placement on the list of disassociated persons with the board at the next closed session. Information contained in an application under subsection (4) is exempt from disclosure under section 4c of this act and is not open for public inspection. The information shall be disclosed to the board, each casino licensee in this state, the department of attorney general, and the department of state police.
(7) The list of disassociated persons shall be provided to each casino licensee, the department of attorney general, and the department of state police.
(8) Each casino licensee in this state shall submit to the board a plan for disseminating the information contained in the applications for placement on the list of disassociated persons. The board shall approve the plan. The plan shall be designed to safeguard the confidentiality of the information but shall include dissemination to all of the following:
(a) The general casino manager or the managerial employee who has responsibility over the entire casino operations.
(b) All security and surveillance personnel.
(c) The department of state police.
(9) A casino licensee shall not extend credit, offer check cashing privileges, offer coupons, market its services, or send advertisements to, or otherwise solicit the patronage of, those persons whose names are on the list of disassociated persons.
(10) The casino licensee shall keep a computer record of each individual whose name is on the list of disassociated persons. If a casino licensee identifies a person on the premises of a casino, the licensee shall immediately notify the board, a representative of the board, or a representative of the department of state police who is on the premises of the casino. After the licensee confirms that the individual has filed an affidavit under this section, the licensee shall do all of the following:
(a) Immediately remove the individual from the casino premises.
(b) Report the incident to the prosecutor for the county in which the casino is located.
(11) A casino licensee who violates this act is subject to disciplinary action by the board.
(12) The board shall promulgate rules to implement and administer this act.
(13) An individual who has placed his or her name on the list of disassociated persons who enters a casino in this state is guilty of criminal trespassing punishable by imprisonment for not more than 1 year, a fine of not more than $1,000.00, or both.
(14) This act does not create any right or cause of action on behalf of the individual whose name is placed on the list of disassociated persons against the state of Michigan, the board, or a casino licensee.
(15) Any winnings collected by the board under this act shall be deposited into the compulsive gaming prevention fund.
Michigan Gaming Control Board
Application for Placement on the List of Disassociated Persons
Full Legal Name of Applicant:
______(First Name) (Middle Name) (Last Name)
Home Address:
______(Number and Street)
______
(City) (State) (Zip Code)
Social Security Number:
______- _____ - ______/Driver’s License Number:
______/ Driver’s License State: ______Date of Birth: ______/______/______
(Month / Day / Year) /
Home Telephone Number: (______)______
(Area Code and Number)Maiden, Alias or Other Names Used: ______
Employment Information:
Occupation: ______Business Telephone Number: (______)______
(Area Code and Number)
Business Address: ______
(Number and Street) (City) (State) (Zip Code)
Sex: ð Male ð Female / Height: ______/ Weight: ______
Hair Color: ______/ Eye Color: ______
Skin Color/Race: ð American Indian/Alaskan Native ð Asian/Pacific Islander
ð Black (African American) ð Hispanic ð White
Multiracial: ð Yes ð No (Multiracial is defined as a person who belongs to more than one race or have a parent who is multiracial)
Tattoos (Describe): ______
Other Noticeable Physical Characteristics (Describe): ______Cell or Other Telephone Number: ______
Casino Players Card Account Information: ______
Page 2 - Application for Placement on the List of Disassociated Persons
By completing and filing this sworn Application for Placement on the Michigan Gaming Control Board ("Board") List of Disassociated Persons, I knowingly and voluntarily state and affirm under oath that I understand the following questions by marking a “Y” to indicate my answer is “yes” and a “N” to indicate my answer is “no” in the space provided to the left of the question.
______(1) Do you read and understand the English language? (An answer of “no”, terminates the application process unless the applicant provides a translator (signature of translator required on page 3 of application.)
______(2) Are you presently under the influence of any alcoholic beverages, controlled substances or prescription medication that would prevent you from making a sober and informed decision regarding whether or not to execute this application? (An answer of “yes” terminates the application process.)
______(3) Are you completing this application of your own free will, without undue pressure or force? (An answer of “no” terminates the application process.)
______(4) Do you believe and acknowledge that you are a problem gambler and, as a result are seeking treatment and wish to be placed on the Board’s List of Disassociated Persons?
______(5) Do you pledge not to visit, enter, or be present in any casino in the City of Detroit licensed by the Board under the Michigan Gaming Control and Revenue Act, as amended, 1997 PA 69, MCL 432.201 et seq. ("the Act");
______(6) Do you fully authorize the Board and its staff to release the contents of this Application only to all casino licensees in the State of Michigan that operate casinos licensed in the City of Detroit under the Act, and to the Board, the Department of Attorney General, and the Department of State Police, and their respective members, officers, employees and agents?
______(7) Do you understand that the Act and the filing of this Application and your placement on the Board's List of Disassociated Persons does not create any rights or causes of action on your behalf against the State of Michigan, the Board, the Department of Attorney General, the Department of State Police, the casino licensees, or their respective members, officers, employees or agents, and is exempt from public disclosure and not open for public inspection?
______(8) In consideration of placement on the Board's List of Disassociated Persons, do you hereby release, relinquish and give up any and all claims, actions, or rights of action that you have or may have against the State of Michigan, the Board, the Department of Attorney General, the Department of State Police, all casino licensees, and their respective members, officers, employees and agents for any and all injury or harm that you may incur or suffer as a consequence of completing and filing this Application and being added to and placed on the Board's List of Disassociated Persons?
(9) Do you fully understand and authorize all of the following:
______(a) that if you enter or are found present on the premises of a licensed casino in the City of Detroit,
Michigan, you will be immediately arrested and removed from the premises and prosecuted for criminal trespass, punishable by imprisonment for not more than 1 year, a fine of not more than $1,000.00, or both, pursuant to Section 25 of the Act; and?
______(b) that if you enter a licensed casino in the City of Detroit and win any money, or equivalent chips,
tokens or credits as a result of participating in gambling games at the casino, the Board will confiscate all such winnings from you and deposit them into the state's compulsive gaming prevention fund?
Page 3 - Application for Placement on the List of Disassociated Persons
______(10) Do you understand that you will be placed on the Board's List of Disassociated Persons, which will be provided to each casino licensee, the Department of Attorney General and the Department of State Police by the Board?
______(11) Do you understand that placement of your name on the Board's List of Disassociated Persons shall be for the remainder of your life?